Studies have shown that rural Americans have higher rates of chronic disease and poor overall health compared to those living in urban areas. They suffer higher incidence of disease and disabilities, increased mortality, cand lower life expectancies. In rural America, we find fewer job opportunities, a poorer population, and social isolation which all increase the risk for poor health. Also fewer health care practitioners, especially doctors, increases the healthcare risks for this typically older and poorer population.

We also see a disparity in healthcare insurance coverage within this vulnerable population. Very few have employer provided insurance nor do they qualify for Medicaid. These and many other issues we face as APN’s in providng quality care to our rural population. 

The Agency of Healthcare and Research and Quality (AHRQ) is developing initiatives to address healthare disparitiesThe Agency of Healthcare Research and promotes the use of four steps:

1. Developing a collaborative process of research involving researchers and community representatives
2. Recognizing the community as a unit of identity
3. Building on the strengths of resources within the community
4. Facilitating collaborative, equitable partnerships in all phases of research and utilizing an empowering process
5. Promoting co-learning and capacity building among all partners
6. Integrating knowledge generation and intervention for the mutual benefit of all partners.
7. Emphasizing the local relevance of public health problems and multiple determinates of health and disease including biomedical, social, economic and physical environmental factors.
8. Findings can be disseminated to all partners

This method benefits the rural community through the knowledge gained and the resources provided as well as developing a partnership with diverse experts to address the complex health issues. Utilizing the research findings specific interventions can be developed for the under served and may help eliminate rural health disparities.

1. As advanced practice nurses, how can we begin to eliminate disparities in rural underserved areas?   

Instructions:

Use an APA 7 style and a minimum of 350 words. Provide support from a minimum of at least three (3) scholarly sources. The scholarly source needs to be: 1) evidence-based, 2) scholarly in nature, 3) Sources should be no more than five years old (published within the last 5 years), and 4) an in-text citation. citations and references are included when information is summarized/synthesized and/or direct quotes are used, in which APA style standards apply. 

• Textbooks are not considered scholarly sources. 

• Wikipedia, Wikis, .com website or blogs should not be used.

ORIGINAL ARTICLE

Rural Healthy People 2020: New Decade, Same Challenges
Jane N. Bolin, RN, JD, PhD;1 Gail R. Bellamy, PhD;2 Alva O. Ferdinand, DrPH, JD;1 Ann M. Vuong, MPH, DrPH;3

Bita A. Kash, MBA, PhD;1 Avery Schulze, BS;1 & Janet W. Helduser, MA1

1 Department of Health Policy & Management, Texas A&M School of Public Health, College Station, Texas
2 Florida Blue Center for Rural Health Research and Policy, Department of Behavioral Science and Social Medicine, Florida State University College of
Medicine, Tallahassee, Florida

3 Division of Epidemiology, Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio

Funding: Rural Healthy People 2020 is funded
through the generous support of the Texas

A&M School of Public Health at Texas A&M

Health Science Center, College Station, Texas.

For further information, contact: Jane N. Bolin,

RN, JD, PhD, Department of Health Policy &

Management, Texas A&M School of Public

Health, TAMU-1266, College Station, TX

77843-1266; e-mail: jbolin@sph.tamhsc.edu.

doi: 10.1111/jrh.12116

Abstract

Purpose: The health of rural America is more important than ever to the
health of the United States and the world. Rural Healthy People 2020’s goal is to
serve as a counterpart to Healthy People 2020, providing evidence of rural stake-
holders’ assessment of rural health priorities and allowing national and state
rural stakeholders to reflect on and measure progress in meeting those goals.
The specific aim of the Rural Healthy People 2020 national survey was to iden-
tify rural health priorities from among the Healthy People 2020’s (HP2020)
national priorities.
Methods: Rural health stakeholders (n = 1,214) responded to a nationally
disseminated web survey soliciting identification of the top 10 rural health
priorities from among the HP2020 priorities. Stakeholders were also asked to
identify objectives within each national HP2020 priority and express concerns
or additional responses.
Findings and Conclusions: Rural health priorities have changed little in
the last decade. Access to health care continues to be the most frequently iden-
tified rural health priority. Within this priority, emergency services, primary
care, and insurance generate the most concern. A total of 926 respondents
identified access as the no. 1 rural health priority, followed by, no. 2 nutrition
and weight status (n = 661), no. 3 diabetes (n = 660), no. 4 mental health
and mental disorders (n = 651), no. 5 substance abuse (n = 551), no. 6 heart
disease and stroke (n = 550), no. 7 physical activity and health (n = 542), no.
8 older adults (n = 482), no. 9 maternal infant and child health (n = 449), and
no. 10 tobacco use (n = 429).

Key words access, Healthy People 2020, RHP2020, rural disparities, Rural
Healthy People 2020.

The health of rural America is more important than
ever to the overall health of the United States.1 Rural
populations and regions serve the nation not only as
an “agricultural and resource basket” providing people
with needed crops and raw resources for an increasingly
hungry nation and the world,2 but they also provide
important recreational and historic opportunities and
cultural experiences. According to the 2010 US Census
Bureau data, 59 million people, or 17% of the US
population, live in rural or remote communities. Yet,
only 9% of doctors and 16% of registered nurses practice

in rural areas.3,4 Rural America also has a documented
undersupply of nurse practitioners, dentists, pharmacists,
and limited access to specialty care, including but not
limited to general surgery and obstetrics.3 Rural hospital
closures that left many rural counties without a hospital
in the 1980s had slowed with the passage of federal leg-
islation creating special categories of rural hospitals (eg,
critical access hospitals [CAHs]) with special protections.
However, rural hospital closures appear to be on the
rise again due to cutbacks in Medicare reimbursement,
reduced funding, and imminent deadlines for instituting

326 The Journal of Rural Health 31 (2015) 326–333 c© 2015 The Authors The Journal of Rural Health published by Wiley Periodicals, Inc. on behalf of National Rural Health Association
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the

original work is properly cited and is not used for commercial purposes.

Bolin et al. RHP 2020: New Decade, Same Challenges

electronic medical records.5 At the same time, relative to
urban America, mortality and longevity rates are falling
behind in rural America, particularly for females.6,7

In the decade since the publication of Rural Healthy
People 2010,8 rural Americans have continued to cobble
together scarce resources to address the needs of their
local and regional public health infrastructure. Often
these challenges are more severe, and sometimes in-
surmountable, for rural racial and ethnic minorities or
disabled persons living in rural areas. Some rural regions,
such as the US-Mexico border and rural Appalachia,
face third-world living conditions leading to significantly
higher rates of preventable vector borne diseases and
preventable or avoidable chronic diseases.9,10

It would be a mistake to characterize rural America as
exclusively white, when in fact rural communities reflect
the diversity of cultures, tribes, and sects that have settled
in towns, counties, and regions across the country. Rural
communities in the Deep South are very different from
those in the Midwest or in the Southwest. For example,
rural West Virginia is very different from rural Arizona.
Even within states such as Texas, rural populations east
of Interstate Highway-35 are different from rural commu-
nities west of I-35, and both are quite different from rural
counties along the US-Mexico border. The diversity of ru-
ral populations reflects the migration patterns of various
ethnic groups, both historically and more recently those
seeking political or religious asylum, that have come (or
been brought) to the United States and settled across the
nation with their values, cultures, and beliefs.

No matter where they live, rural residents are far more
likely to face significant challenges and disparities. Ac-
cording to US Census Bureau data, poverty rates among
rural black, non-Hispanic (32.2%), and Hispanic (27.8%)
populations were significantly higher than those same
populations living in urban/metro areas.11 Moreover, the
poverty rate for children living in rural areas (23.5%) is
somewhat higher than for children living in poor inner
city urban areas (20.2%). Overall poverty rates are also
higher in rural areas (16.6%) compared to urban (13.9%)
areas. Nationally, two-thirds of rural counties have
poverty rates at or above the national average of 14.4%.12

Poverty is a major risk factor for poor health outcomes
and is more prevalent in rural and inner city areas than
suburban areas.13 Although the population of rural
America overall has continued to grow, 750 rural coun-
ties experienced a natural decrease (deaths exceeding
the number of births) over this last decade, 36% versus
22% in the last decade of the 20th century.14 In Florida,
poverty in rural counties is now at a historically high
level (20.3%). Poverty rates are higher among rural
minority populations, especially in the rural Southeast
and along the border, while many in rural Appalachia,

and the Colonias along the Texas-Mexico border, still
live without running water or electricity.9,10 In a rather
provocative piece, Galambos,15 argued that rural health
disparity has been a “neglected frontier.”

During the past decade, the percent of rural elderly
was greater than urban elderly (15% compared to 12%).
Moreover, in a quarter of nonmetropolitan counties the
percent of rural elderly was 18% or greater.16 Growth
in the number of rural elderly is the result of 2 forces,
1 attributed to outward migration of young people and,
the other, the inward migration of elderly retirees. These
forces are felt differentially across America because those
elderly retirees migrating into rural are more likely to
be healthier physically and better-off economically than
those rural elderly that are aging-in-place. Although ag-
ing is associated with an increase in chronic illness, the
prevalence is likely to be lower among the former.

Rural America is also becoming more diverse. The 2010
census showed minorities accounting for 82.7% of the in-
crease in nonmetropolitan populations, even though they
represented just 21% of the rural population.16 McGuire
et al argued that place (setting) and race (composition)
combine to account for the use of health services, even
when controlling for medical needs.17 The health status of
rural minorities is not only worse than rural whites, but
rural minorities are also poorer than their urban coun-
terparts. It is well documented that living in a rural area
brings higher risk of substantial health disadvantages in
comparison to both urban and suburban areas.18,19

Poverty, age, increasing racial/ethnic diversity, and in-
frastructure needs are not the only challenges faced by
rural Americans. Educational attainment is also lower,
with a greater proportion of rural residents not complet-
ing high school compared to urban residents, and a lessor
proportion of rural residents attending and/or complet-
ing college than urban residents.18,20 Rural residents also
face substantial disadvantages in terms of employment
opportunities. For example, since the national economic
downturn and recession of 2008, urban and suburban
areas have returned to their prerecession employment
rates, but rural or nonmetro areas have not recovered
or seen overall net employment growth.20,21 Risk of on-
the-job injury also remains consistently higher for rural
workers, including higher mortality and morbidity due
to traumatic injuries associated with agriculture, mining,
forestry, and fishing.22

Healthy People23 has served the nation since the 1980s
by providing a consensus statement of national priorities
and outcome benchmarks to serve as measures for the
nation’s health. Healthy People goals and objectives are
intended to serve as a guide for action by national, state
and local entities to improve the health of communities
over the course of a decade. However, Healthy People

The Journal of Rural Health 31 (2015) 326–333 c© 2015 The Authors The Journal of Rural Health published by Wiley Periodicals, Inc. on behalf of National Rural Health Association 327

RHP 2020: New Decade, Same Challenges Bolin et al.

considers “rurality” to be just one of 14 disparities con-
tributing to poor health.

Healthy People 2020 [HP2020] defines a health disparity as

“a particular type of health difference that is closely linked with
social, economic, and/or environmental disadvantage. Health
disparities adversely affect groups of people who have system-

atically experienced greater obstacles to health based on their
racial or ethnic group; . . . ..geographic location; [rural]
or other characteristics historically linked to discrimination or

exclusion.”24

Although rural health disparities are 1 of 14 disparity
concerns of Healthy People, there has not been a focus
or an effort by the Healthy People planners to support
focused evaluation for rural states and rural communities
that exist within largely urban states which would allow
measurement of progress. Moreover, for many HP2020
objectives there are insufficient data to evaluate rurality
as a disparity.4

The goal of Rural Healthy People 2020 (RHP2020) is to
identify those HP2020 focus areas that are priorities for
rural America, and to provide focused reviews of the re-
search and policy literature highlighting rural disparities
and needs of rural populations. Ideally, RHP2020 should
serve as an important resource for both national and state
health policy planners and a tool for rural community
leaders. We conducted a national survey of rural health
stakeholders to address part 1 of the goal, to identify the
priority HP2020 focus areas for rural America.

Design and Methods

We utilized a survey questionnaire similar to that em-
ployed by RHP2010 a decade earlier but utilized elec-
tronic dissemination rather than mail. The survey listed
the 38 HP2020 focus areas and respondents were asked
to identify or check the “Top 10” they considered to
be the most important for rural America. The RHP2020
survey can be viewed at http://www.chotnsf.org/survey/
rhp2020/ruralhealthypeople2020.htm.

Respondents were then invited to identify more spe-
cific objectives within each identified rural health priority
(Question 2), and to identify the single highest ranking
rural health priority (Question 3). The survey also asked
for respondents’ state of residence, stakeholder organi-
zation, and profession. The remaining questions solicited
information not reported herein.

This first phase of the RHP2020 study
was intended to answer the following
questions:

1. What changes, if any, are there in rural stakehold-
ers’ health priorities over the past decade since Rural
Healthy People 2010?

2. Are there differences in identified rural health priori-
ties within and across US Census Bureau regions?

3. Do rural priorities differ, and if so how do they differ,
across stakeholder groups and regions of the United
States?

The survey was launched electronically, via web and
e-mail invitation in all states, regions, and possessions
of the United States in December 2010 with web-link
dissemination assistance from the National Rural Health
Association (NRHA), National Organization of the State
Offices of Rural Health (NOSORH), the National Area
Health Education Center (AHEC) Organization, and the
National Rural Assembly. The survey link was open until
January 11, 2011. A total of 679 survey responses were
received during this time period. Due to low participation
rates in the Southeastern United States, the survey was
relaunched in August 2012 in order to better target
those low response states. The RHP2020 survey relaunch
was preceded by a webinar sponsored by NOSORH for
its members and others to learn more about RHP2020.
Letters were also sent to select Commissioners of Health
in the southern states to increase the probability of
southern stakeholder involvement. With assistance from
leaders of national rural health associations, electronic
notice about the second RHP2020 survey launch was
included in their virtual communications to members,
with a reminder that original respondents should not
respond twice to the survey. The survey link remained
open for 30 days. The final overall response to the
RHP2020 survey totaled 1,214.

The Rural Healthy People research study was originally
approved by the Texas A&M University Institutional Re-
view Board (IRB) as IRB No. 2003–0361M, and it was
reapproved for RHP2020.

Results

Figures 1 and 2 identify responses by state, with Ohio and
Texas leading all states for number of respondents with
147 and 129 respondents, respectively. Ninety-six rural
stakeholders participated from Missouri followed by West
Virginia (57), Michigan (51), and Indiana (47).

States with fewer than 10 respondents are shown in
Figure 2. Only 1 state, Nevada, failed to participate in the
RHP2020 survey.

Results by Census Regions, (Table 1), shows that the
Northeast Census region had 86 (7%), respondents, the
Western Census region had a total of 170 respondents
(14%), the South region had 435 respondents (36%),
and the Midwest had the greatest number, 504 (42%).
As shown in Table 1, there was variation in response rates
both by Census region and also by Department of Health
and Human Services (DHHS) region, with the Midwest

328 The Journal of Rural Health 31 (2015) 326–333 c© 2015 The Authors The Journal of Rural Health published by Wiley Periodicals, Inc. on behalf of National Rural Health Association

Bolin et al. RHP 2020: New Decade, Same Challenges

Figure 1 States With 10 or > Respondents.

Figure 2 States With 9 or < Respondents.

region and specifically Ohio, having the highest number
of respondents (DHHS Region 5) at 325 respondents.

The respondents demonstrated broad stakeholder
participation across professional categories, with 34%

identifying themselves as rural administrators, 29%
identifying themselves as rural providers, 15% as rural
educators, 4% as rural researchers, and 2.2% as students.
However, 24% listed themselves as “Other.” Nearly 75%

The Journal of Rural Health 31 (2015) 326–333 c© 2015 The Authors The Journal of Rural Health published by Wiley Periodicals, Inc. on behalf of National Rural Health Association 329

RHP 2020: New Decade, Same Challenges Bolin et al.

Table 1 RHP2020 Survey: Respondent Characteristics

No. %a

Respondents’ census regions a

West 170 14.2

Midwest 504 42.2

South 434 36.3

Northeast 87 7.3

Respondents’ DHHS regions

Region 1—Boston 48 4.0

Region 2—New York 19 1.6

Region 3—Philadelphia 130 10.9

Region 4—Atlanta 124 10.4

Region 5—Chicago 325 27.2

Region 6—Dallas 202 16.9

Region 7—Kansas City 134 11.2

Region 8—Denver 108 9.0

Region 9—San Francisco 33 2.8

Region 10—Seattle 72 6.0

Respondents’ profession b

Provider 353 29.1

Administrator 417 34.4

Educator 185 15.2

Researcher 47 3.9

Student 27 2.2

Other 286 23.6

Organizational level of employmentb

Statewide 292 25.3

Local 862 74.7

Statewide organization a

SORH 52 18.2

State Primary Care Association 11 3.8

State Rural Health Association 19 6.5

Other 210 71.9

Local organization b

Rural public health agency 159 18.5

FQHC or rural health clinic 102 11.8

Community health center 37 4.3

Rural hospital (CAH) 234 27.2

Pharmacy 5 0.6

Human services agency 54 6.3

Other 300 34.8

aBased on nonmissing responses.
bMore than one response could have been selected.

of respondents worked for a local (county, city, or town)
organization, while 25.3% worked at the statewide
level. Of those who worked at the statewide level,
18.2% (53) worked for one of the State Offices of Rural
Health (SORH), while 6.5% worked for a state rural
health association and 3.8% worked for a state primary
care association. The majority (71.9%) self-identified
as working at the local level. Respondents who were
employed locally included employees and administrators
of rural hospitals, particularly CAHs (27.2% respon-
dents); employees of federally qualified or rural health

centers (11.8%); and employees of rural public health
agencies (18.5%). Four percent of respondents worked
for a human services agency, while less than 1% was
rural pharmacists. Rural hospital employee was the most
commonly identified professional employment (234),
followed by rural public health agency (159), and FQHC
or rural health clinic (102).

Top Rural Health Priorities for This
Decade

The survey asked rural stakeholders to identify which
of the 38 focus areas of Healthy People 2020 they con-
sidered one of the top 10 priorities for rural pop-
ulations. (See: http://www.chotnsf.org/survey/rhp2020/
ruralhealthy people2020.htm). Each focus area has a
lengthy list of subobjectives and goals listed in the
HP2020 draft objectives originally released in 2009 and
formally launched on December 2, 2010. Survey respon-
dents were asked to identify or select their top 10 rural
priorities. The results of the top 10 rankings offer rich in-
formation about rural stakeholders’ opinions on the most
pressing rural health issues for this decade. The results
allow analysis of rural health priorities across US Cen-
sus regions as well as across DHHS regions of the United
States. Like a decade earlier, “access” received the most
votes from all respondents. A total of 926 (76%) identi-
fied access as a top 10 rural health priority (Figure 3).

Access to quality health services was also identified as
the single most important rural health priority for the
decade by over one-third of the respondents (n = 441).
Following access (in order of votes received), were nutri-
tion and weight status (661 votes/55%), diabetes (660
votes/54%), mental health and mental disorders (651
votes/54%), substance abuse (551 votes/45%), heart dis-
ease and stroke (550 votes /45%), physical activity and
health (542 votes /45%), older adults (482 votes/40%),
maternal, infant and child health, (449 votes/37%), and
tobacco use rounding out the top 10 identified rural
health priorities receiving (429 votes/35%; Table 2).

Cancer continued to rank high as a national rural
health priority, receiving top 10 votes from 428 re-
spondents (35%), while educational and community-
based programs received 400 top 10 votes from 33% of
respondents.

Discussion

The Rural Healthy People 2020 study provides support for
rural stakeholders in addressing state and local rural
health needs and providing national representatives with
documentation of rural stakeholders’ priorities. Our goal
was to collect and summarize the data from the survey

330 The Journal of Rural Health 31 (2015) 326–333 c© 2015 The Authors The Journal of Rural Health published by Wiley Periodicals, Inc. on behalf of National Rural Health Association

Bolin et al. RHP 2020: New Decade, Same Challenges

Figure 3 Rural Healthy People National Survey: Most Important Rural Priorities.

to enable rural stakeholders to address rural-specific
agendas and priorities across state and local governments
and national policy makers. In particular, the goal was
to assist those agencies whose mission and mandate is
addressing public health and acute care rural workforce
shortages, program funding, and infrastructure needs.
While HP2020 provides goals and benchmarks for the
nation’s health by addressing health disparities and poor
health outcomes, RHP2020 is dedicated to rural health
explicitly, with the goal of improving the health of the
close to 20% of Americans who live in rural areas.
While access is certainly an important issue for rural
health, there is a growing body of evidence that scarcity
of jobs, poverty, and the environment all contribute
to predicting physical and mental health. Town hall
meetings held in rural communities across the United
States have identified a variety of concerns including
building rural community infrastructure, cross-sector
communication and transportation that impact on
health.25,26

Within the context of HP2020, the RHP2020 study
continues to be instrumental in identifying those areas

of greatest concern to rural stakeholders, while the
larger RHP2020 project also works to pull together what
is known about the rural experience in these priority
focus areas, documenting health status and treatment
differentials in rural versus urban areas, outcomes
associated with interventions and care, and rural versus
urban access challenges. RHP2020 provides additional
evidence that rural health disparities, poverty, race,
and ethnicity are strongly linked to geographic (rural)
differences in health care. The identification of RHP2020
priorities positions rural organizations to communicate
these priorities to their state and local organizations as
well as communicate effectively with national represen-
tatives. The identification of priorities provides a focus for
research, for policy development, and for rural programs.
In addition, RHP2020 should assist rural stakeholders
in identifying resource needs, and provide reliable rural
data establishing priorities and assisting with monitoring
RHP2020 progress on stakeholder identified objectives.

The full results of the RHP2020 survey, including sub-
objectives volunteered by respondents, may be viewed at
http://sph.tamhsc.edu/srhrc/index.html.

The Journal of Rural Health 31 (2015) 326–333 c© 2015 The Authors The Journal of Rural Health published by Wiley Periodicals, Inc. on behalf of National Rural Health Association 331

RHP 2020: New Decade, Same Challenges Bolin et al.

Table 2 Selection as a “Top 10” Rural Healthy People 2020 Priority, Nationally and by Census Region

Overall West Midwest South Northeast

Priorities No. % No. % No. % No. % No. %

Access to quality health services 926 76.3 138 81.2 374 74.2 325 74.9 72 82.8

Nutrition and weight status 661 54.5 80 47.1 286 56.8 232 53.5 52 59.8

Diabetes 660 54.4 79 46.5 275 54.6 241 55.5 53 60.9

Mental health and mental disorders 651 53.6 81 47.7 280 55.6 229 52.8 53 60.9

Substance abuse 551 45.4 72 42.4 235 46.6 190 43.8 46 52.9

Heart disease and stroke 550 45.3 74 43.5 241 47.8 182 41.9 46 52.9

Physical activity and health 542 44.7 70 41.2 244 48.4 180 41.5 36 41.4

Older adults 482 39.7 71 41.8 188 37.3 175 40.3 39 44.8

Maternal, infant, and child health 449 37.0 57 33.5 188 37.3 166 38.3 34 39.1

Tobacco use 429 35.3 53 31.2 188 37.3 139 32.0 39 44.8

Cancer 428 35.2 55 32.4 174 34.5 162 37.3 35 40.2

Educational and community-based programs 400 33.0 60 35.3 162 32.1 146 33.6 31 35.6

Oral health 381 31.4 47 27.7 174 34.5 132 30.4 21 24.1

Quality of life and well-being 327 26.9 46 27.1 132 26.2 119 27.4 26 29.9

Immunizations and infectious diseases 324 26.7 43 25.3 139 27.6 113 26.0 24 27.6

Public health infrastructure 315 26.0 46 27.1 129 25.6 110 25.4 25 28.7

Family planning and sexual health 278 22.9 38 22.4 113 22.4 101 23.3 22 25.3

Injury and violence prevention 265 21.8 36 21.2 110 21.8 89 20.5 26 29.9

Social determinants of health 258 21.3 35 20.6 115 22.8 87 20.1 18 20.7

Health communication and health IT 257 21.2 38 22.4 105 20.8 85 19.6 22 25.3

Limitations

As with any research there are limitations to the national
RHP2020 study. First, several respondents pointed out
that exclusive focus on HP2020 priority areas may
not include unique concerns of rural stakeholders, as
evidenced by the 175 votes for other issues. Second,
as Table 1 shows, most respondents are health care
providers or administrators, and/or work for health
care-related organizations at state or local levels. Thus,
respondents may have focused on rural priorities that
one could argue represent financial self-interest versus
objective needs. Third, we did not collect information on
the racial/ethnic background of respondents. A final, but
important, limitation is that we do not know the actual
response rate for the survey since it was hosted on Web
sites, or disseminated via e-mail by several rural health
organizations, including NRHA, NOSORH, and Rural Re-
search Gateway, among others. Additionally, and related
to response rate, the first launch of the survey resulted in
an underrepresentation of some states, including several
states in the Southeast United States. Thus, we made
the decision to relaunch the survey targeting at least 10
respondents per state. Despite a second wave of data
collection, there were many states that still had disap-
pointingly low numbers of respondents. However, we
tested for significance differences across US Census re-
gions and there were no significant differences in the top
10 priority areas, suggesting that there is agreement on

issues of importance to rural stakeholders across Census
regions, if not necessarily in the order of importance.

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The Journal of Rural Health 31 (2015) 326–333 c© 2015 The Authors The Journal of Rural Health published by Wiley Periodicals, Inc. on behalf of National Rural Health Association 333